REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). Gift ownership) Estate Private Sale Other (or no change in Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: CAD OR USD NOTES:
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). Gift Estate Private Sale Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: CAD OR USD CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. All securityholders or a legally authorized representative must sign this form. The signature(s) on this form must be guaranteed in accordance with the transfer agent’s then current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards): • Canada and the USA: A Medallion Signature Guarantee obtained from a member of an acceptable Medallion Signature Guarantee Program (STAMP, SEMP, NYSE, MSP). Many commercial banks, savings banks, credit unions, and all broker dealers participate in a Medallion Signature Guarantee Program. The Guarantor must affix a stamp bearing the actual words “Medallion Guaranteed”, with the correct prefix covering the face value of the certificate. • Canada: A Signature Guarantee obtained from an authorized officer of the Royal Bank of Canada, Scotia Bank or TD Canada Trust. The Guarantor must affix a stamp bearing the actual words “Signature Guaranteed”, sign and print their full name and alpha numeric signing number. Signature Guarantees are not accepted from Treasury Branches, Credit Unions or Caisse Populaires unless they are members of a Medallion Signature Guarantee Program. For corporate holders, corporate signing resolutions, including certificate of incumbency, are also required to accompany the transfer, unless there is a “Signature & Authority to Sign Guarantee” Stamp affixed to the transfer (as opposed to a “Signature Guaranteed” Stamp) obtained from an authorized officer of the Royal Bank of Canada, Scotia Bank or TD Canada Trust or a Medallion Signature Guarantee with the correct prefix covering the face value of the certificate.
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). Gift Estate Private Sale Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: CAD OR USD CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. All securityholders or a legally authorized representative must sign this form. The signature(s) on this form must be guaranteed in accordance with the transfer agent’s then current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards):
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). ☐ Gift ☐ Estate ☐ Private Sale ☐ Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: ☐ CAD OR ☐ USD CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. All securityholders or a legally authorized representative must sign this form. The signature(s) on this form must be guaranteed in accordance with the transfer agent’s then current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards):
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below).
REASON FOR TRANSFER. Upon written request, reasons for involuntary reassignment shall be given to the teacher in writing, as soon as determined.
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). ☐ Gift ☐ Estate ☐ Private Sale ☐ Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: / / $ . ☐ CAD OR ☐ USD CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. All securityholders or a legally authorized representative must sign this form. The signature(s) on this form must be guaranteed in accordance with the transfer agent’s then current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards):
REASON FOR TRANSFER. FOR US CITIZENS OR RESIDENTS ONLY Consistent with US IRS regulations, AST is required to request cost basis information from US securityholders. Please indicate the reason for requesting the transfer as well as the date of event relating to the reason. The event date is not the day in which the transfer is finalized, but rather the date of the event which led to the transfer request (i.e. date of gift, date of death of the securityholder, or the date the private sale took place). SCHEDULE “B” EXERCISE FORM TO: Algernon Pharmaceuticals Inc. (the “Corporation”) AND TO: AST Trust Company (Canada) 1600 - 0000 Xxxx Xxxxxxxx Xx. Xxxxxxxxx, XX V6E 3X1 The undersigned holder of the Warrants evidenced by this Warrant Certificate hereby exercises the right to acquire (A) Common Shares of Algernon Pharmaceuticals Inc. Exercise Price Payable: ((A) multiplied by $0.55, subject to adjustment) The undersigned hereby exercises the right of such holder to be issued, and hereby subscribes for, Common Shares that are issuable pursuant to the exercise of such Warrants on the terms specified in such Warrant Certificate and in the Warrant Indenture. The undersigned hereby acknowledges that the undersigned is aware that the Common Shares received on exercise may be subject to restrictions on resale under applicable securities legislation. Any capitalized term in this Warrant Certificate that is not otherwise defined herein, shall have the meaning ascribed thereto in the Warrant Indenture. The undersigned represents, warrants and certifies as follows (one (only) of the following must be checked):
REASON FOR TRANSFER. For US Citizens or Residents only (where the individual(s) or corporation receiving the securities is a US citizen or resident). Please select only one (see instructions below). ☐ Gift ☐ Estate ☐ Private Sale ☐ Other (or no change in ownership) CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. All securityholders or a legally authorized representative must sign this form. The signature(s) on this form must be guaranteed in accordance with the transfer agent's then-current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards):
REASON FOR TRANSFER. For US Residents only (where the individual(s) or corporation receiving the securities is a US resident). Please select only one (see instructions below). [ ] Gift [ ] Estate [ ] Private Sale [ ] Other (or no change in ownership) Date of Event (Date of gift, death or sale): Value per Warrant on the date of event: [ ] CAD OR [ ] USD CERTAIN REQUIREMENTS RELATING TO TRANSFERS – READ CAREFULLY The signature(s) of the transferor(s) must correspond with the name(s) as written upon the face of this certificate(s), in every particular, without alteration or enlargement, or any change whatsoever. The signature(s) on this form must be guaranteed in accordance with the transfer agent’s then current guidelines and requirements at the time of transfer. Notarized or witnessed signatures are not acceptable as guaranteed signatures. As at the time of closing, you may choose one of the following methods (although subject to change in accordance with industry practice and standards): • Canada and the USA: A Medallion Signature Guarantee obtained from a member of an acceptable Medallion Signature Guarantee Program (STAMP, SEMP, NYSE, MSP). Many commercial banks, savings banks, credit unions, and all broker dealers participate in a Medallion Signature Guarantee Program. The Guarantor must affix a stamp bearing the actual words “Medallion Guaranteed”, with the correct prefix covering the face value of the certificate.
